Appendix IV: Turnitin Report
Chapter 3: Theoretical Framework
Introduction
This study adopts the Social Ecology Model for Communication and Health Behaviour (SEMCHB) as the framing model to be used to investigate the role of community leaders in strengthening the implementation of oral PrEP amongst adolescent girls and young women (AGYW) in Vulindlela. The SEMCHB is a multi-layered model that seeks to understand health communication across different levels of interaction ranging from the individual to the environmental level as these are all crucial in understanding contexts where health decisions are made in communities. However, for the purpose of this study, the researcher focused on two layers of the model, which are, the individual and the community level to understand how community leaders can influence the decision of AGYW to take up oral PrEP as an effective health intervention to prevent HIV infection. To conceptualise the study within the SEMCHB, the study further adopted the Health Belief Model (HBM) which seeks to explore the individual layer of the framework through understanding the perceptions and the role of community leaders as individuals in promoting or enabling the adoption of oral PrEP among AGYW in their communities. The HBM explored the knowledge and perceptions of the community leaders about oral PrEP, the perceived risk and susceptibility of AGYW to HIV infections. Furthermore, the Culture Centred Approach (CCA) was adopted to explore the influence of culture amongst community leaders and the role it played in constituting health meanings and decisions. This chapter begins with a detailed discussion of the SEMCHB and how it relates to the study. It further discusses the HBM, its constructs and their relevance to the study. Lastly, it provides a discussion of the CCA and links it to the overall study.
The Social Ecology Model for Communication and Health Behaviour (SEMCHB)
The SEMCHB originates from the Social Ecology Model (SEM) which was aimed at understanding the dynamic interrelations among various personal and environmental factors (Bronfenbrenner, 1979). Social ecology models view individual health
32 decisions as part of a collective or a broader social system (Golden et al., 2012). In other words, while the individual has the responsibility to make positive health decisions but the contextual factors and other actors such as the community, government, policy positions also play a significant role in the adoption of positive health behaviours for improved health outcomes. Bronfenbrenner who was among the first to propose a multi-layered framework to health promotion focused on human development. He interrogated how human beings create environments in which they live, exploring how humans are influenced by their immediate environments in the adoption of health interventions that promote positive health behaviour adoption (Bronfenbrenner, 1979). What is key to ecological models is systems thinking, which is the way to understand how things can influence one another within a whole considering that health decisions are not made in isolation from the broader social system (Bronfenbrenner, 1979).
During the earlier years of health communication, more emphasis was on individual- level theories of learning, persuasion and decision making on health behaviour and behaviour change (Storey and Figuerora, 2012). Psychosocial theories such as Reasoned Action/Planned Behaviour and Social Cognitive Theory that were used in most health programs, even though successfully measured communication processes and outcomes reliably, they overemphasized individual-level behaviour change (Storey and Figuerora, 2012). Hence critics of this individualistic approach had concerns about the missing theoretical elements, that is, community level processes and their contribution to health outcomes. Such criticism led to the bridging of gap by challenging theorists and practitioners to move towards a socio-ecological perspective on health communication. Social ecology is defined as “the study of the influence of the social context on behaviour, including institutional and cultural variables” (Sallis and Owen (2002:462).
As a framework, the SEMCHB moves beyond the initial understanding of health communication and decision making as a responsibility of an individual. It is an evolution of theories of behaviour and social change that emphasises a shift from looking at communication as a one-time, one way communicative ‘act’ to a multi-level dialogue which unfolds over a period of time (Storey and Figueroa, 2012). Some authors have argued that theories do not progress as a series of successive rejections of earlier models but resemble biological evolution of a simple organism into a more
33 complex one (Neuman and Guggenheim, 2011 in Storey and Figueroa, 2012). This applies to the theory of health communication where communication has been seen to strengthen many aspects of human agency and creating change at all levels, be it individual, family, community or societal levels (Storey and Figueroa, 2012).
Furthermore, the SEMCHB illustrates the complexity, interrelatedness and wholeness of the components of a complex adaptive system, rather than just particular components in isolation from the system. Embeddedness and emergence are two main features of this model (Storey and Figueroa, 2012). Embeddedness refers to a state in which one system is nested in a hierarchy of other systems at different levels of analysis, and emergence, in which the system at each level is greater than the sum of its parts (Storey and Figueroa, 2012). It is for these reasons that the SEMCHB was used as a relevant framework to underpin the study because even in the case of Vulindlela, it is important to understand the role of community leaders in influencing the adoption of oral PrEP among AGYW using a holistic approach realising that AGYW cannot make health decisions in isolation from their communities.
The SEMCHB has four levels of interaction that influence health decision making (Bronfenbrenner, 1979; Lindridge et al., 2013). The first layer of the framework is the individual level which recognises the individual’s attributes, attitude and perceptions towards a health condition and how these influence health behaviour of an individual (Lindridge et al., 2013). The individual level suggests that the adoption of specific health behaviours can either be repressed or encouraged by personal incentive, intent and demographic profile (Lindridge et al., 2013; O’Donnell, 2005). However, individual health decision making is also dependent on the parents’ awareness, educational background and attitude towards the health behaviour (Holme et al., 2009; Lindridge et al., 2013), thereby suggesting that this level alone is not sufficient for the adoption of health interventions. In the context of this study, AGYW in Vulindlela are unable to solely make the decision to adopt oral PrEP as a prevention intervention outside other factors of influence. This means the other levels of the framework are equally important in HIV prevention among AGYW in the community of Vulindlela.
The second layer of the SEMCHB is the social networks level which seeks to understand the social constructs such as family and friends and how they encourage positive health behavior adoption for an individual (Lindridge et al., 2013). This level
34 recognises the role of families, friends and social networks in health communication and promotion. In other words, the decision by AGYW to adopt oral PrEP could be greatly influenced by their families and friends and that could either be a positive or a negative influence. However, in the main the interpersonal relationships remain key in decision making within the SEMCHB framework.
The community level is the third layer of the SEMCHB framework which focusses on the involvement of the community in encouraging mutual efficacy (Cohen et al., 2006;
Green and Tones, 2011; Kauppi, 2015; Lindridge et al., 2013; Ragnarsson et al., 2011). Within this level, there are different influences such as the community structures constituting community leaders, schools, businesses and others who have a role in influencing the adoption of a health intervention. Likewise, community leaders in Vulindlela within this framework are also understood to have a critical role in directing the health behaviour of AGYW. A positive exercise of their influence on the topic of oral PrEP adoption among AGYW could lead to positive outcomes for the young women. Hence, it is important for the purposes of this study to understand the influential role of community leaders in Vulindlela on the adoption of oral PrEP among AGYW. This layer of interaction is likely to contest already established social norms and may result in resistance from the community to the promoted health change (Lindridge et al., 2013).
The fourth and last layer is the societal level which recognises the wider societal factors that influence health decision making these include government, policies, social and cultural factors. The societal level further refers to the cultural components of an individual’s life as well as the expectations placed on the individual (Lindridge et al., 2013). In this context, it can be assumed that a positive cultural belief can contend with structures that limit access to that health behaviour (Corcoran, 2013; Dupas, 2011; Kauppi, 2015; Kelly et al., 2005; Lindridge et al., 2013). When the community has the relevant information regarding the health concern and there are relevant and enabling policies in place then individuals and communities become more willing and able to adopt the preventative health behaviour in order to achieve positive health outcomes (Corcoran, 2013; Kickbush et al., 2008; Lindridge et al., 2013; Nutbeam, 2000). However, when individuals and communities are less informed or aware of the health concern then this becomes a challenge to health communication and the ability and willingness of communities to adopt a behavior change (Atkinson et al., 2011;
35 Babalola et al., 2006; Kauppi, 2015; Lindridge et al., 2013; Nielsen-Bohlman et al., 2004; Riehman et al., 2013).
Understanding how these different layers of the SEMCHB interact allows researchers to address and act on them in a way that leads to a positive behavioural change (Bronfenbrenner, 1979; Lindridge et al., 2013). An example of this interaction within this framework is captured in this illustration: an individual is born into a family, he or she learns through socialisation the norms and values of the society. S/he interacts with peers at school and learn new ways of doing things. Throughout this process, there is communication that takes place and it is what links all the stages of growth of an individual. Communication is of paramount importance in all these stages of growth and in all the relationships formed. There is a dialogue that takes place, and this makes it possible to understand human behaviour. In fact, to understand human behaviour, both the individual and social context need to be understood.
The SEMCHB framework offers a comprehensive approach to understanding health communication and the adoption of changed health behaviours. The interactions between the different levels are key to attaining a positive health outcome and this is also true for this study of exploring the role of community leaders on the adoption of oral PrEP among AGYW in Vulindlela. This study acknowledges the importance of all the layers of interaction of the framework but only focuses on two levels for the purposes of this study. The study explores in detail the individual and the community level of the framework. The individual level is important in understanding the perceptions of community leaders on the issue of HIV prevention for AGYW as understanding this provides insights on their willingness as leaders to support or reject the adoption of oral PrEP. Furthermore, community leaders are placed within the community level of the framework as they have influence in determining behaviour of their communities. Thus, understanding the challenges and opportunities in the community to promote PrEP is important for this study. In order to ensure sustainability, this study adopts the assumption that when individual change is facilitated and supported by social changes at higher levels it is more likely to be self- sustaining. This means the AGYW in Vulindlela would be more successful in taking oral PrEP if they are supported by community leaders who can mobilise resources for them to ensure sustainability and positive outcomes from the intervention.
36 Figure 1. Source: Kincaid et.al (2007)
Panter-Brick et.al (2005) argue that for health interventions to be successful, emphasis should be put on community members who are receptive to change. They further state that interventions should be ‘culturally compelling’ that is, local communities’
engagement is very important (Panther-Brick et.al, 2005). In a study they conducted in malaria prevention in Gambia they examined interactions of people within their social and physical environment using social ecology model of behaviour change (Panter-Brick et.al, 2005).
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The Health Belief Model (HBM)
The Health Belief Model is a psychological model that seeks to explain an individual’s behaviour through predictions. The HBM focuses on understanding the perceptions of an individual towards a health condition and the proposed interventions and predicts the extent to which an individual will be willing to adopt the health intervention (Tarkang and Zotor, 2015). The assumption that led to the development of this model was that individuals are generally scarred of diseases and getting sick, however, their response to preventing the sickness relies on the extent to which the cure will benefit them more and have less harmful effects (Hochbaum, 1958; Rosenstock, 1966).
The Health Belief Model was developed in the 1950s by social psychologists who sought to describe the poor participation of people on diseases prevention programmes (Glanz et.al 2002). In 1952, Hochbaum (1958) conducted a study with a sample of 200 adults with the aim of exploring their readiness to obtain X-rays taken in tuberculosis screening. This study was aimed at understanding their perceptions on their susceptibility to tuberculosis and perceptions on the perceived personal benefits of early detection. The findings showed that 82% of the sample realised their susceptibility to the disease and the benefits of early detection (Glanz et.al 2002).
Through this study it was evident that there is strong association between the individual’s perceptions of susceptibility to a health condition and the benefits of a health intervention to ease the susceptibility (Glanz et.al 2002). Similarly, another research study found that the frequency of dental visits can be predicted by perceived susceptibility to dental problems (Glanz et.al 2002). In this way, the HBM specifies the beliefs that are responsible for certain health behaviour patterns which can be addressed by educational intervention (Kegeles, 1963).
According to Metta (2016), the Health Belief Model has been valuable in the successful application of many diseases and health issues amongst adults. It has been shown to be effective in increasing voluntary screening for cervical cancer, breast cancer, participation in support groups dealing with cancer, chronic disease controlling, adult physical activity classes, vaccinations and the prevention of HIV and perceptions of risk with this disease (Bailey, 2008; Brewer et al., 2007; Champion and Menon, 1997;
Clark et al., 1988; Hay et al., 2003; Juniper et al., 2004; Metta, 2016; Orji et al., 2012;
Sherman et al., 2008; Taylor et al., 2007; Winfield and Whaley, 2002). This model
38 emphasizes the role of an individual and the individuals’ choices in terms of their perceived notions to cause a change in their behaviour (Metta, 2016; Tanner-Smith and Brown, 2010). The major drawback of this model is the attempt to isolate the individual and remove other social factors such as culture, tradition and other group behaviours that contribute to the way an individual may think, perceive and behave (MacKian, 2003; Metta, 2016; Roden, 2004).
There is a shift from the HBM being used for screening behaviours to include preventive actions. This supports the relevance of the use of HBM in this study as its focus is on the role of community leaders in effective implementation of oral PrEP amongst the AGYW of Vulindlela. This study was conducted to determine the overall attitude and knowledge of oral PrEP amongst community leaders for AGYW in Vulindlela. The HBM was used to further understand perception of risk and barriers/enablers of community leaders. The researcher also aimed to find out what community leaders envisaged as perceived benefits for AGYW to oral PrEP uptake.
The HBM further allowed the researcher to explore what could prompt the community leaders to take positive action towards promoting oral PrEP uptake. Taking into consideration the predictive power that the HBM has, the researcher attempted to use it in finding out how community leaders are likely to influence positively or negatively the AGYW because of their beliefs and perceptions. Here the concept of community efficacy (Dutta 2008) would be examined.
Key constructs of the HBM
According to Metta (2016), seeking to improve one’s health is a conditioned behaviour that when viewed from the point of inspiring people to seek out specific health care needs, a thorough understanding of their motivation for this should be achieved. For the successful implementation of any health intervention, it is valuable to gain a profound understanding of the complex factors that make up common behavioural practices (Metta, 2016). Once the understanding of behaviour is achieved, the health promotion can be tailored to ensure that it is introduced into people’s lives efficiently and effectively (Metta, 2016). The HBM as a model involves the personal beliefs and insights about a disease by an individual and how this affects their health behaviour (Hochbaum, 1958). It also prods on the approaches that need to be developed in order
39 to decrease the occurrence of the current health problem (Hochbaum, 1958). The HBM has 6 constructs that seek to predict health behaviour, and these will be discussed in detail below.
Perceived susceptibility
Perceived susceptibility refers to an individual’s belief or attitude towards the risk of contracting a health condition (Glanz et.al 2002; DiClemente and Peterson, 1994).
This construct suggests that individuals assess their risk levels or extent of their susceptibility to a health condition before adopting a health behavioural change or intervention. If the perceived risk is considered as significant such as having detrimental effects on the physical components of a human being, causes great physical pain, or any other human associated discomfort and displeasure, then the more likely it will be for an individual to adopt the behaviour that will reduce the risk of them contracting the debilitating disease (de Wit et al., 2005; Metta, 2016; Taylor et al., 2007). An example of this would be homosexual men obtaining vaccinations to prevent contraction of Hepatitis B and also adopting the use of condoms during sexual acts to prevent the likelihood of contracting HIV/AIDS (Belcher et al., 2005; de Wit et al., 2005). Another example of perceived susceptibility is in people who choose to obtain vaccinations for the flu virus (Chen et al., 2007). Individuals are motivated to adopt a health behaviour when they strongly believe that they are prone to the infection thereby making them susceptible to the condition.
The opposite is also likely to occur which is a disadvantage of this construct. If a person believes they are not susceptible to a health condition or if they perceive that they have very low susceptibility, they tend not to adopt preventative measures available to them and may even adopt unhealthy behaviours. An example of this is in the case of older adults who choose not to protect themselves against HIV/AIDS during sexual acts since they perceive that they have lower chances of being infected (Maes and Louis, 2003; Metta, 2016; Taylor et al., 2007). Similarly, in another study, Asian American college students opted not to protect themselves during sexual acts since they had the perception that HIV/AIDS was not an Asian epidemic, hence they were at a lower risk for contracting the disease (Yep, 1993). While individual perceptions of susceptibility are important, they are not always correct and sometimes increases the